Sikka Dental Annual Health Update Form
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General Patient Update:
Patient FULL Name (First Last )
Patient Date of Birth - or- Birth YEAR:
Patient Marital Status:
Is patient a Minor (under age 18 yrs old)?
Best Contact Phone Number (include area code):
Do you consent in electronic communication from Sikka Dental?
Do you have a preferred method of contact?
Current Email Address
Main Phone/Cell Number with Area Code Please
Current Mailing Address, City, State, Zip Code
Emergency Contact (Name / Contact Details / Relation to patient):
I have read and understand the following Disclaimer Statement: As a courtesy to our patients, Sikka Dental Corporation will help file insurance claim forms to your insurance carrier in an effort to collect account balances. Sikka Dental Corporation cannot guarantee or warrant any insurance payments, claim payments are paid based upon your groups plan provisions and limitations that are selected by your employer. Plan changes are subject to change without notice to Sikka Dental and unforeseen circumstances are a possibility. Any lack of payment from your insurance carrier will result in monies due to Sikka Dental Corporation and will need to be paid under the office policies and procedures in a timely manner.
Yes, I understand the above disclaimer statement
Are you currently a patient of record with your Medical Doctor?
When was your last medical visit?
Name of Physician (First and Last Name) and Contact details (Phone and/or Fax)
Patient Medical Record/ID # with medical coverage?
Have you been hospitalized with in the last 2 years? Please explain more details on question #10.
WOMAN ONLY: Are you Pregnant?
1. ALLERGIES: Please select all that apply to presently or conditions in the past:
Penicillin or other antibiotics
Valium or other sedatives
Codeine or other narcotics
I HAVE NO KNOWN ALLEGERIES TO ANY OF THE ABOVE LISTED ITEMS. I HAVE READ ALL ABOVE OPTIONS AND NONE APPLY TO ME AT THIS TIME.
2. Have you ever experienced any of the following? Please mark all that apply:
Recent significant weight loss
Coughing up blood
Blood in urine
Blood in stools
Diarrhea or constipation
Ringing in ears
Joint pain or stiffness
Shortness or breath
I HAVE NEVER EXPERIENCED ANY OF THE ABOVE LISTED CONDITIONS. I HAVE READ ALL ABOVE OPTIONS AND NONE APPLY TO ME AT THIS TIME.
3. Have you ever had or do you have any of the following? Please mark all that apply.
Family history or heart disease
Stomach problems or ulcers
Hardening of arteries
High blood pressure
Family history of diabetes
Tumors or Cancer
Emphysema / other lung disease
Kidney or bladder disease
Sexual transmitted disease
Canker or cold sores
I DO NOT HAVE ANY HISTORY OF THE ABOVE LISTED CONDITIONS. I HAVE READ ALL ABOVE OPTIONS AND NONE APPLY TO ME AT THIS TIME.
4. Are you taking or have you taken any of the following? Please mark all that apply.
Over the counter medicines
Weight loss medications
Tobacco in any form
I HAVE NOT EVER TAKEN ANY OF THE ABOVE MENTIONED ITEMS. I HAVE READ ALL ABOVE OPTIONS AND NONE APPLY TO ME AT THIS TIME.
5. Do you have or have you had any other diseases or medical problems NOT listed on this form? Please use question #10 to explain.
6. Have you ever been pre-medicated for dental treatment? Please use question #10 to explain.
7. Have you ever taken Fen-Phen?
8. Is there any issue or condition that you would like to discuss with the dentist in PRIVATE?
9. Please list any Current Medications you are taking: (Drug Name / Condition the Drug is treating / Dosage or Frequency of Drug) You may also email or text these details into the office.
10. If there is any additional conditions or information that you have not already provided or listed above please use this space provided:
To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of the team, responsible for any errors or omissions that I may have made in the complete of this form.
Yes, I attest to my replies to this form to be accurate.
Electronic Signature (Please type your full name)
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